Testimony 

Before the Subcommittee on Oversight 

and Investigations, Committee on 

Veterans’ Affairs, House of 

Representatives

United States General Accounting Office 

GAO

For Release on Delivery 

Expected at 2:00 p.m.

Wednesday, May 7, 2003 VA HEALTH CARE 

VA Increases Third-Party 

Collections as It Addresses 

Problems in Its Collections 

Operations 

Statement of Cynthia A. Bascetta 

Director, Health Care—Veterans’ 

 Health and Benefits Issues 

GAO-03-740T 
VA’s fiscal year 2002 third-party collections rose by 32 percent over fiscal 

year 2001 collections, to $687 million, and available data for the first half of 

fiscal year 2003 show that $386 million has been collected so far. The 

increase in collections reflects VA’s improved ability to manage the larger 

billing volume and more itemized bills required under its new fee schedule. 

VA managers in three regional health care networks attributed billings 

increases to a reduction of billing backlogs and improved collections 

processes, such as better medical documentation prepared by physicians, 

more complete identification of billable care by coders, and more bills 

prepared per biller. 

Although collections are increasing, operational problems, such as missed 

billing opportunities, persist and continue to limit the amount VA collects. 

VA has been implementing the action items in its Revenue Cycle 

Improvement Plan of September 2001 that are designed to address 

operational problems, such as unidentified insurance for some patients, 

insufficient documentation of services for billing, shortages of billing staff, 

and insufficient pursuit of accounts receivable. VA reported in April 2003 

that 10 of 24 action items are complete; 7 are scheduled for implementation 

by the end of 2003; and the remaining actions will begin in 2004 with full 

implementation expected in 2005 or 2006. These dates are behind VA’s 

original schedule. In addition, the Chief Business Office, established in May 

2002, has developed a new approach that combines the action items with 

additional initiatives. 

Given the growing demand for care, especially from higher-income veterans, 

it is important that VA resolve its operational problems and sustain its 

commitment to maximizing third-party collections. It is also important for 

VA to develop a reliable estimate of uncollected dollars and a complete 

measure of its collections costs. Without this information, VA cannot 

evaluate its effectiveness in supplementing its medical care appropriation 

with third-party dollars. 

The Department of Veterans Affairs 

(VA) collects health insurance 

payments, known as third-party 

collections, for veterans’ health 

care conditions it treats that are 

not a result of injuries or illnesses 

incurred or aggravated during 

military service. In September 

1999, VA adopted a new fee 

schedule, called “reasonable 

charges,” that it anticipated would 

increase revenues from third-party 

collections. 

In January 2003, GAO reported on 

VA’s third-party collection efforts 

and problems in collections 

operations for fiscal year 2002 as 

well as VA’s initiatives to improve 

collections (VA Health Care: 

Third-Party Collections Rising as 

VA Continues to Address Problems 

in Its Collections Operations, 

[GAO-03-145, Jan. 31, 2003]). GAO 

was asked to discuss its findings 

and update third-party collection 

amounts and agency plans to 

improve collections. 

www.gao.gov/cgi-bin/getrpt?GAO-03-740T.

To view the full testimony click on the link 

above. For more information, contact Cynthia 

A. Bascetta at (202) 512-7101. 

Highlights of GAO-03-740T, a testimony 

before the Subcommittee on Oversight 

and Investigations, Committee on 

Veterans’ Affairs, House of 

Representatives 

May 7, 2003 

VA HEALTH CARE 

VA Increases Third-Party Collections as It 

Addresses Problems in Its Collections 

Operations 
Page 1 GAO-03-740T 

Mr. Chairman and Members of the Subcommittee: 

I am pleased to be here today to discuss the Department of Veterans 

Affairs’ (VA) progress in collecting insurance payments for care provided 

at VA facilities from eligible veterans’ private health insurers. Known as 

third-party collections, these collections are VA’s largest source of revenue 

to supplement its medical care appropriation, and they help pay for 

veterans’ growing demand for care. The total number of veterans VA 

treated has increased from 2.6 million in fiscal year 1996 to 4.3 million in 

fiscal year 2002, and VA predicts continuing growth in its patient 

workload. Higher income veterans or those without service-connected 

disabilities have comprised a significant portion of this growth, and thirdparty collections are intended to help pay for the cost of their care. 

Over the past several years, concerns have been raised about VA’s ability 

to maximize its third-party collections to enhance revenues. We testified in 

September 2001 that problems in VA’s collections operations—such as 

inadequate patient intake procedures to gather insurance information, 

insufficient physician documentation, a shortage of qualified coders, and 

insufficient automation—diminished VA’s collections.1

 Concerned about 

these issues you asked that we report on (1) trends in VA’s third-party 

collections, (2) problems in collections operations, and (3) VA’s approach 

for improving collections. My comments today are based on a report we 

issued to this subcommittee on January 31, 2003.2

 For that work, we 

examined VA’s collections data for fiscal years 2001 and 2002 and available 

data for 2003; reviewed relevant VA documents, such as the Veterans 

Health Administration’s (VHA) Revenue Cycle Improvement Plan of 

September 2001; and interviewed officials in VA headquarters and in 3 of 

VA’s 21 health care networks3

—Network 2 (Albany), Network 9 

(Nashville), and Network 22 (Long Beach). At your request, we updated 

information in that report on third-party collection amounts and agency 

 1

U.S. General Accounting Office, VA Health Care: VA Has Not Sufficiently Explored 

Alternatives for Optimizing Third-Party Collections, GAO-01-1157T (Washington, D.C.: 

Sept. 20, 2001). 

2

U.S. General Accounting Office, VA Health Care: Third Party Collections Rising as VA 

Continues to Address Problems in Its Collections Operations, GAO-03-145 (Washington, 

D.C.: Jan. 31, 2003). 

3

The management of VA’s hospitals and other health care facilities is decentralized to 21 

regional networks. 
Page 2 GAO-03-740T 

plans to improve collections. We did our work in accordance with 

generally accepted government auditing standards. 

In summary, VA’s third-party collections for fiscal year 2002 totaled 

$687 million, 32 percent more than for fiscal year 2001, and available data 

for the first half of fiscal year 2003 show that $386 million has been 

collected so far. Although VA reported an increase in collections, we found 

that operational problems, such as missed billing opportunities, continued 

to limit collections. As a result, VA lacks a reliable estimate of uncollected 

dollars and therefore does not have the basis to assess its systemwide 

operational effectiveness. In May 2002, VA established the Chief Business 

Office (CBO) in VHA to develop a new approach for VA’s collections 

activity. VA officials told us that CBO’s approach would combine the VHA 

Revenue Cycle Improvement Plan of September 2001 (2001 Improvement 

Plan) with additional initiatives, such as the development of an automated 

financial system that better serves billing needs and additional 

performance measures and standards for overseeing collection units’ 

activities. Since the introduction of the 2001 Improvement Plan, VA has 

made some progress in resolving operational problems, such as fully 

implementing electronic billing, mandating the use of electronic medical 

records, and using preregistration software. However, given today’s tight 

budget environment, it is important that VA resolve its operational 

problems and sustain its attention and commitment to maximizing thirdparty collections. 

Although VA has been authorized to collect third-party health insurance 

payments since 1986, it was not allowed to use these funds to supplement 

its medical care appropriations until enactment of the Balanced Budget 

Act of 1997. Part of VA’s 1997 strategic plan was to increase health 

insurance payments and other collections to help fund an increased health 

care workload. The potential for increased workload occurred in part 

because the Veterans’ Health Care Eligibility Reform Act of 1996 

authorized VA to provide certain medical care services not previously 

available to higher-income veterans or those without service-connected 

disabilities. VA expected that the majority of the costs of their care would 

be covered by collections from third-party payments, copayments, and 

deductibles. These veterans increased from about 4 percent of all veterans 

treated in fiscal year 1996 to about a quarter of VA’s total patient workload 

in fiscal year 2002. 

Background 
Page 3 GAO-03-740T 

VA can bill insurers for treatment of conditions that are not a result of 

injuries or illnesses incurred or aggravated during military service. 

However, VA cannot bill them for health care conditions that result from 

military service, nor is it generally authorized to collect from Medicare or 

Medicaid, or from health maintenance organizations when VA is not a 

participating provider. 

To collect from health insurers, VA uses five related processes to manage 

the information needed to bill and collect. The patient intake process 

involves gathering insurance information and verifying that information 

with the insurer. The medical documentation process involves properly 

documenting the health care provided to patients by physicians and other 

health care providers. The coding process involves assigning correct codes 

for the diagnoses and medical procedures based on the documentation. 

Next, the billing process creates and sends bills to insurers based on the 

insurance and coding information. Finally, the accounts receivable 

process includes processing payments from insurers and following up with 

insurers on outstanding or denied bills. 

In September 1999, VA adopted a fee schedule, called “reasonable 

charges.” Reasonable charges are itemized fees based on diagnoses and 

procedures. This schedule allows VA to more accurately bill for the care 

provided. However, by making these changes, VA created additional billprocessing demands—particularly in the areas of documenting care, 

coding that care, and processing bills per episode of care. First, VA must 

accurately assign medical diagnoses and procedure codes to set 

appropriate charges, a task that requires coders to search through medical 

documentation and various databases to identify all billable care. Second, 

VA must be prepared to provide an insurer supporting medical 

documentation for the itemized charges. Third, in contrast to a single bill 

for all the services provided during an episode of care under the previous 

fee schedule, under reasonable charges VA must prepare a separate bill for 

each provider involved in the care and an additional bill if a hospital 

facility charge applies. 

For fiscal year 2002, VA collected $687 million in insurance payments, up 

32 percent compared to the $521 million collected during fiscal year 2001. 

Collections through the first half of fiscal year 2003 total $386 million in 

third-party payments. The increased collections in fiscal year 2002 

reflected that VA processed a higher volume of bills than it did in the prior 

fiscal year. VA processed and received payments for over 50 percent more 

bills in fiscal year 2002 than in fiscal year 2001. VA’s collections grew at a 

Third-Party Collections 

Increased 
Page 4 GAO-03-740T 

lower percentage rate than the number of paid bills because the average 

payment per paid bill dropped 18 percent compared to the prior fiscal 

year. Average payments dropped primarily because a rising proportion of 

VA’s paid bills were for outpatient care rather than inpatient care. Since 

the charges for outpatient care were much lower on average, the payment 

amounts were typically lower as well. 

Although VA anticipated that the shift to reasonable charges in 1999 would 

yield higher collections, collections had dropped in fiscal year 2000. VA 

attributed that drop to its being unprepared to bill under reasonable 

charges, particularly because of its lack of proficiency in developing 

medical documentation and coding to appropriately support a bill. As a 

result, VA reported that many VA medical centers developed billing 

backlogs after initially suspending billing for some care. 

As shown in figure 1, VA’s third-party collections increased in fiscal year 

2001—reversing fiscal year 2000’s drop in collections—and increased 

again in fiscal year 2002. After initially being unprepared in fiscal year 2000 

to bill reasonable charges, VA began improving its implementation of the 

processes necessary to bill and increase its collections. By the end of fiscal 

year 2001, VA had submitted 37 percent more bills to insurers than in fiscal 

year 2000. VA submitted even more in fiscal year 2002, as over 8 million 

bills—a 54 percent increase over the number in fiscal year 2001—were 

submitted to insurers. 
Page 5 GAO-03-740T 

Figure 1: VA’s Third-Party Collections, Fiscal Years 1997 through 2002 

Managers we spoke with in three networks—Network 2 (Albany), 

Network 9 (Nashville), and Network 22 (Long Beach)—mainly attributed 

the increased billings to reductions in the billing backlogs. Networks 2 

(Albany) and 9 (Nashville) reduced backlogs, in part by hiring more staff, 

contracting for staff, or using overtime to process bills and accounts 

receivable. Network 2 (Albany), for instance, managed an increased billing 

volume through mandatory overtime. Managers we interviewed in all three 

networks noted better medical documentation provided by physicians to 

support billing. In Network 22 (Long Beach) and Network 9 (Nashville), 

revenue managers reported that coders were getting better at identifying 

all professional services that can be billed under reasonable charges.4

 In 

addition, the revenue manager in Network 2 (Albany) said that billers’ 

productivity had risen from 700 to 2,500 bills per month over a 3-year 

 4

The revenue manager in Network 9 (Nashville) said that coders were getting better at the 

manual searching that is required to find billable professional services and laboratory tests. 

During fiscal year 2001, coders missed some billable care because of inadequate searches 

through the various sources of information used to document services and tests. 

1997 1998 1999 2000 2001 2002

Fiscal year

Dollars in millions

September 1999

reasonable

charges

implemented

0

100

200

300

400

500

600

700

Source: VA.
Page 6 GAO-03-740T 

period, as a result of gradually increasing the network’s productivity 

standards and streamlining their jobs to focus solely on billing. 

VA officials cited other reasons for the increased number of bills 

submitted to insurers. An increased number of patients with billable 

insurance was one reason for the increased billing. In addition, a May 2001 

change in the reasonable-charges fee schedule for medical evaluations 

allowed separate bills for facility charges and professional service charges, 

a change that contributed to the higher volume of bills in fiscal year 2002. 

Studies have suggested that operational problems—missed billing 

opportunities, billing backlogs, and inadequate pursuit of accounts 

receivable—limited VA’s collections in the years following the 

implementation of reasonable charges. For example, a study completed 

last year estimated that 23.8 percent of VA patients in fiscal year 2001 had 

billable care, but VA actually billed for the care of only 18.3 percent of 

patients.5

 This finding suggests that VA could have billed for 30 percent 

more patients than it actually billed. Further, after examining activities in 

fiscal years 2000 and 2001, a VA Inspector General report estimated that 

VA could have collected over $500 million more than it did.6 About 73 

percent of this uncollected amount was attributed to a backlog of unbilled 

medical care; most of the rest was attributed to insufficient pursuit of 

delinquent bills. Another study, examining only professional-service 

charges in a single network, estimated that $4.1 million out of $4.7 million 

of potential collections was unbilled for fiscal year 2001.7

 Of that unbilled 

amount, 63 percent was estimated to be unbillable primarily because of 

insufficient documentation. In addition, the study found that coders often 

missed services that should have been coded for billing. 

According to a CBO official, VA could increase collections by working on 

operational problems. These problems included unpaid accounts 

receivable and missed billing opportunities due to insufficient 

 5

T. Michael Kashner, Ph.D., J.D., et al., Final Report: Veterans Affairs Patient Health 

Insurance Survey (VAPHIS), a survey funded by the Department of Veterans Affairs, 

February 16, 2002. 

6

Department of Veterans Affairs, Office of Inspector General, Audit of the Medical Care 

Collection Fund Program, Report No. 01-00046-65 (Washington, D.C.: Feb. 26, 2002). 

7

Economic Systems, Inc. and AdvanceMed, Professional Fee Backlog Assistance: Final 

Technical Report, a report prepared for the Department of Veterans Affairs, March 5, 2002. 

Operational Problems 

Limit Collections, but VA 

Lacks an Estimate of 

Uncollected Dollars 
Page 7 GAO-03-740T 

identification of insured patients, inadequate documentation to support 

billing, and coding problems that result in unidentified care. From April 

through June 2002, three network revenue managers told us about 

backlogs and processing issues that persisted into fiscal year 2002. For 

example, although Network 9 (Nashville) had above average increases in 

collections for both inpatient and outpatient care, it still had coding 

backlogs in four of six medical centers. According to Network 9’s 

(Nashville) revenue manager, eliminating the backlogs for outpatient care 

would increase collections by an estimated $4 million, or 9 percent, for 

fiscal year 2002.8

 Additional increases might come from coding all 

inpatient professional services, but the revenue manager did not have an 

estimate because the extent to which coders are capturing all billable 

services was unknown. Moreover, although all three networks reported 

that physicians’ documentation for billing was improving, they also 

reported a continuing need to improve physicians’ documentation. In 

addition, Network 22 (Long Beach) reported that its accounts receivable 

staff had difficulties keeping up with the increased volume of bills because 

it had not hired additional staff members or contracted help on accounts 

receivable. 

As a result of these operational limitations, VA lacks a reliable estimate of 

uncollected dollars, and therefore does not have the basis to assess its 

systemwide operational effectiveness. For example, some uncollected 

dollars result from billing backlogs and billable care missed in coding. In 

addition, VA does not know the net impact of actual third-party collections 

on supplementing its annual appropriation for medical care. For example, 

CBO relies on reported cost data from central office and field staff directly 

involved in billing and collection functions. However, these costs do not 

include all costs incurred by VA in the generation of revenue. According to 

a CBO official, VA does not include in its collections cost the investments 

it has made in information technology or resources used in the 

identification of other health insurance during the enrollment process. 

 8

In September 2002, the revenue manager anticipated that the backlog would be reduced to 

$2 million by the end of fiscal year 2002 because the medical centers had hired new coders 

and the network had created a central pool of seven coders. 
Page 8 GAO-03-740T 

VA continues to implement its 2001 Improvement Plan, which is designed 

to increase collections by improving and standardizing VA’s collections 

processes. The plan’s 24 actions are to address known operational 

problems affecting revenue performance. These problems include 

unidentified insurance for some patients, insufficient documentation for 

billing, coding staff shortages, gaps in the automated capture of billing 

data, and insufficient pursuit of accounts receivable. The plan also 

addresses uneven performance across collection sites. 

The plan seeks increased collections through standardization of policy and 

processes in the context of decentralized management, in which VA’s 21 

network directors and their respective medical center directors have 

responsibility for the collections process. Since management is 

decentralized, collections procedures can vary across sites. For example, 

sites’ procedures can specify a different number of days waited until first 

contacting insurers about unpaid bills and can vary on whether to contact 

by letter, telephone, or both. The plan intends to create greater process 

standardization, in part, by requiring certain collections processes, such as 

the use of electronic medical records by all networks to provide coders 

better access to documentation and legible records. 

When fully implemented, the plan’s actions are intended to improve 

collections by reducing operational problems, such as missed billing 

opportunities. For example, two of the plan’s actions—requiring patient 

contacts to gather insurance information prior to scheduled appointments 

and electronically linking VA to major insurers to identify patients’ 

insurance—are intended to increase VA’s awareness of its patients who 

have other health insurance. 

VA has implemented some of the improvement plan’s 24 actions, which 

were scheduled for completion at various times through 2003, but is 

behind the plan’s original schedule. The plan had scheduled 15 of the 24 

actions for completion through May 25, 2002, but as of that date VA had 

only completed 8 of the actions. Information obtained from CBO in April 

2003 indicates that 10 are complete and 7 are scheduled for 

implementation by the end of 2003. Implementation of the remaining 

actions will begin in 2004 as part of a financial system pilot with full 

2001 Plan to Improve 

Collections Is Partially 

Implemented; Other 

Initiatives Being 

Developed 
Page 9 GAO-03-740T 

implementation expected in 2005 or 2006.9 (Appendix I lists the actions 

and those VA reports as completed through April 28, 2003.) 

In May 2002, VHA established its CBO to underscore the importance of 

revenue, patient eligibility, and enrollment and to give strategic focus to 

improving these functions. Officials in the office told us that they have 

developed a new approach for improving third-party collections that can 

help increase revenue collections by further revising processes and 

providing a new business focus on collections. 

For example, the CBO’s strategy incorporates improvements to the 

electronic transmission of bills and initiation of a system to receive and 

process third-party payments electronically. CBO’s new approach also 

encompasses initiatives beyond the improvement plan, such as the one in 

the Under Secretary for Health’s May 2002 memorandum that directed all 

facilities to refer accounts receivable older than 60 days to a collection 

agency, unless a facility can document a better in-house process. 

According to the Deputy Chief Business Officer, the use of collection 

agencies has shown some signs of success—with outstanding accounts 

receivables dropping from $1,378 million to $1,317 million from the end of 

May to the end of July 2002, a reduction of about $61 million or 4 percent. 

CBO is in the process of acquiring a standardized Patient Financial 

Services System (PFSS) that could be shared across VA. VA’s goal with 

PFSS is to implement a commercial off-the-shelf health care billing and 

accounts receivable software system. Under PFSS, a unique record will be 

established for each veteran. Patient information will be standardized—

including veteran insurance data, which will be collected, managed, and 

verified. Receipts of health care products and services will be added to the 

patient records as they are provided or dispensed. And PFSS will 

automatically extract needed data for billing, with the majority of billings 

sent to payers without manual intervention. After the system is acquired, 

VA will conduct a demonstration project in Network 10 (Cincinnati).10

 9

One action item was cancelled but its intended improvements will be incorporated into an 

automated financial system initiative. 

10In the conference report accompanying its fiscal year 2002 appropriation, VA was directed 

to begin a demonstration project of a patient financial services system installed and 

operated by a contractor. H.R. Conf. Rep. No. 107-272, at 56 (2001). 
Page 10 GAO-03-740T 

According to the Deputy Chief Business Officer, in May 2003 VA 

anticipates awarding a contract for the development and implementation 

of PFSS. CBO’s plan is to install this automated financial system in other 

facilities and networks if it is successfully implemented in the pilot site. 

CBO is taking action on a number of other initiatives to improve 

collections, including the following: 

• Planning and developing software upgrades to facilitate the health care 

service review process and electronically receive and respond to requests 

from insurers for additional documentation. 

• Establishing the Health Revenue Center to centralize preregistration, 

insurance identification and verification, and accounts receivable 

activities. For example, during a preregistration pilot in Network 11 (Ann 

Arbor), the Health Revenue Center made over 246,000 preregistration 

telephone calls to patients to verify their insurance information. According 

to VA, over 23,000 insurance policies were identified, resulting in 

$4.8 million in collections. 

• Assessing its performance based on private sector performance metrics, 

including measuring the pace of collections relative to the amount of 

accounts receivable. 

As VA faces increased demand for medical care, particularly from higherincome veterans, third-party collections for nonservice-connected 

conditions remain an important source of revenue to supplement VA’s 

appropriations. VA has been improving its billing and collecting under a 

reasonable-charges fee schedule it established in 1999, but VA has not 

completed its efforts to address problems in collections operations. In this 

regard, fully implementing the 2001 Improvement Plan could help VA 

maximize future collections by addressing problems such as missed billing 

opportunities. CBO’s initiatives could further enhance collections by 

identifying root causes of problems in collections operations, providing a 

focused approach to addressing the root causes, establishing performance 

measures, and holding responsible parties accountable for achieving the 

performance standards. 

Our work and VA’s continuing initiatives to improve collections indicate 

that VA has not collected all third-party payments to which it is entitled. In 

this regard, it is important that VA develop a reliable estimate of 

uncollected dollars. VA also does not have a complete measure of its full 

collections costs. Consequently, VA cannot determine how effectively it 

supplements its medical care appropriation with third-party collections. 

Concluding 

Observations 
Page 11 GAO-03-740T 

Mr. Chairman, this concludes my prepared remarks. I will be pleased to 

answer any questions you or other members of the subcommittee may 

have. 

For further information regarding this testimony, please contact 

Cynthia A. Bascetta at (202) 512-7101. Michael T. Blair, Jr. and Michael 

Tropauer also contributed to this statement. 

Contact and 

Acknowledgments 
Page 12 GAO-03-740T 

Appendix I: 2001 Improvement Plan Status as 

of April 28, 2003 
Page 13 GAO-03-740T 

a

Certain actions are mandated in the plan, that is, are required, but these actions are not legal or 

regulatory mandates. 

b

One action item was cancelled but its intended improvements will be incorporated into an automated 

financial system initiative. 

c

VA designated the electronic billing project, shown here as “17a,” as completed. However, this 

indicated only partial completion of action 17, which includes an additional project. 
Page 14 GAO-03-740T 

VA Health Care: Third Party Collections Rising as VA Continues to 

Address Problems in Its Collections Operations. GAO-03-145. Washington, 

D.C.: January 31, 2003. 

VA Health Care: VA Has Not Sufficiently Explored Alternatives for 

Optimizing Third-Party Collections. GAO-01-1157T. Washington, D.C.: 

September 20, 2001. 

VA Health Care: Third-Party Charges Based on Sound Methodology; 

Implementation Challenges Remain. GAO/HEHS-99-124. Washington, 

D.C.: June 11, 1999. 

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